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Alcohol Use Disorders: Diagnosis and Clinical Management of Alcohol-Related Physical Complications [Internet]

Alcohol is the most widely used psychotropic drug in the industrialised world; it has been used for thousands of years as a social lubricant and anxiolytic. In the UK, it is estimated that 24% of adult men and 13% of adult women drink in a hazardous or harmful way. Levels of hazardous and harmful drinking are lowest in the central and eastern regions of England (21–24% of men and 10–14% of women). They are highest in the north (26–28% of men, 16–18% of women). Hazardous and harmful drinking are commonly encountered amongst hospital attendees; 12% of emergency department attendances are directly related to alcohol whilst 20% of patients admitted to hospital for illnesses unrelated to alcohol are drinking at potentially hazardous levels. Continued hazardous and harmful drinking can result in dependence and tolerance with the consequence that an abrupt reduction in intake might result in development of a withdrawal syndrome. In addition, persistent drinking at hazardous and harmful levels can also result in damage to almost every organ or system of the body. Alcohol-attributable conditions include liver damage, pancreatitis and the Wernicke’s encephalopathy. Key areas in the investigation and management of these conditions are covered in this guideline.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: 2010
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At this time, benzodiazepines cannot be recommended for the treatment of non‐alcohol related delirium

A systematic review of benzodiazepine treatment of non‐alcohol related delirium discovered very few trials (one randomized, controlled study of mechanically ventilated patients, and thus poorly reflective of delirious patients as a whole; and two partially controlled studies), the results of which indicate that at this time there is no evidence to support the use of benzodiazepines in the treatment of non‐alcohol withdrawal related delirium among hospitalised patients.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

The role of diazepam loading for the treatment of alcohol withdrawal syndrome in hospitalized patients

BACKGROUND: Alcohol withdrawal accounts for a significant amount of hospital admissions and can quickly progress to the development of delirium tremens (DTs), seizures, and death. Rapid identification and management of alcohol withdrawal syndrome (AWS) is vital and can be managed with a number of different treatment strategies. Diazepam loading is a treatment strategy that utilizes the pharmacokinetics of this agent to achieve a rapid reduction in symptoms followed by sustained benefit over a period of days.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

Benzodiazepines for alcohol withdrawal

This Cochrane review summarizes evidence from sixty‐four randomised controlled trials evaluating the effectiveness and safety of benzodiazepines in the treatment of alcohol withdrawal symptoms. The available data show that benzodiazepines are effective against alcohol withdrawal seizures when compared to placebo and a potentially protective benefit for many outcomes when compared with other drugs. Data on safety outcomes are sparse and fragmented.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Magnesium for the prevention or treatment of alcohol withdrawal syndrome in adults

Alcohol withdrawal syndrome (AWS) is a set of symptoms experienced when one reduces or stops alcohol consumption after prolonged periods of alcohol intake. Some studies show that AWS coincides with low levels of magnesium in the blood. Since magnesium may play a role in dampening the excitability of the central nervous system, some researchers believe that low levels of magnesium may make the central nervous system 'hyper‐excitable' and may cause AWS symptoms, which include sleeplessness, tremors, anxiety, headache, excessive sweating and reduced appetite. Many AWS treatment protocols therefore recommend magnesium supplementation.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Gamma‐hydroxybutyrate for treating symptoms associated with alcohol withdrawal and preventing relapses for people who are dependent on alcohol

Excessive long term alcohol consumption can lead to dependence on alcohol. This means that when a person stops drinking suddenly he or she experiences withdrawal symptoms. The main goals for clinical management of alcohol withdrawal are to minimize the severity of symptoms and facilitate entry into a treatment program, so that the person can achieve and maintain abstinence from alcohol. Symptoms of withdrawal range from tremor, nausea, anxiety, restlessness and insomnia to more severe effects such as seizures, hallucinations, agitation and delirium. Progression to coma and cardiac arrest is possible. Medications that are intended to help people who are dependent on alcohol to withdraw from it include benzodiazepines, anticonvulsants and gamma‐hydroxybutyrate (GHB). GHB was first available as a health food and body‐building supplement, but reports of adverse events led to its withdrawal for that purpose.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Delirium (PDQ®): Health Professional Version

Expert-reviewed information summary about delirium as a complication of cancer or its treatment. Supportive care and pharmacologic approaches to the management of delirium are discussed.

PDQ Cancer Information Summaries [Internet] - National Cancer Institute (US).

Version: July 30, 2014

Delirium: Diagnosis, Prevention and Management [Internet]

This guideline covers adult patients (18 years and older) in a hospital setting and adults (18 and older) in long-term residential care. The guideline addresses: modifiable risk factors (‘clinical factors’) to identify people at risk of developing delirium; diagnosis of delirium in acute, critical and long-term care; as well as pharmacological and non-pharmacological interventions for a) reducing the incidence of delirium and its consequences, and b) to reduce the severity, duration and consequences of delirium in people who develop the condition.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: July 2010
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Delirium: Screening, Prevention, and Diagnosis – A Systematic Review of the Evidence [Internet]

Delirium is a common syndrome in hospitalized or institutionalized adults. It is characterized by the acute onset of altered mental status, hallmarked by difficulty sustaining attention and a fluctuating course. Delirium frequently causes patients, families, and health care providers considerable distress. The incidence varies widely based on patient population, setting, and intensity of diagnostic ascertainment with reported values of 10% to over 80%. Delirium is associated with multiple serious outcomes including increased morbidity, length of hospital stay, healthcare costs, institutionalization, and mortality. In surgical settings, older adults and those with multiple medical conditions are at increased risk for postoperative delirium. Delirium may be under-recognized by healthcare providers and it can be difficult to resolve. Several brief “bedside” questionnaires and checklists exist that can help detect delirium earlier and among those with milder symptoms. Additionally, efforts to prevent the development of delirium in those at risk have been advocated. Medications (including sedatives, narcotics, and anticholinergic drugs), diseases and intercurrent illnesses (e.g., stroke, infection, shock, anemia), surgical procedures (especially orthopedic and cardiac surgery), and environmental factors (e.g., use of a bladder catheter, pain, and emotional stress) are all associated with delirium. Therefore, identifying and implementing effective strategies to prevent and detect delirium could improve clinical outcomes and resource utilization. Suggested strategies to prevent delirium include avoidance of psychoactive medications, pharmacologic interventions to decrease risk, and single- or multi-component non-pharmacologic interventions (including use of music, mobilization, fluid and nutrition management, and orientation and cognitive stimulation).

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: September 2011
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Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence

This clinical guideline on alcohol-use disorders was commissioned by NICE and developed by the National Collaborating Centre for Mental Health, and sets out the evidence for the treatment and management of harmful drinking and alcohol dependence in adults and in young people aged 10 to 17 years.

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK).

Version: 2011
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Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices

To review important patient safety practices for evidence of effectiveness, implementation, and adoption.

Evidence Reports/Technology Assessments - Agency for Healthcare Research and Quality (US).

Version: March 2013

Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet]

To assess the effectiveness of screening followed by behavioral counseling for adolescents and adults with alcohol misuse in primary care settings.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: July 2012

Dementia: A NICE-SCIE Guideline on Supporting People With Dementia and Their Carers in Health and Social Care

This guideline has been developed to advise on supporting people with dementia and their carers in health and social care. The guideline recommendations have been developed by a multidisciplinary team of health and social care professionals, a person with dementia, carers and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to practitioners and service commissioners in providing and planning high-quality care for those with dementia while also emphasising the importance of the experience of care for people with dementia and carers.

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK).

Version: 2007
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Drug Class Review: Newer Drugs for Insomnia: Final Report Update 2 [Internet]

Insomnia is a serious health problem that affects millions of people. Population surveys have estimated the prevalence of insomnia to be about 30% to 50% of the general population. About three-fourths of people who have trouble sleeping say that the problem is "occasional," averaging about 6 nights per month, with one-fourth having frequent or chronic insomnia, averaging about 16 nights per month. Individuals with insomnia most often report a combination of difficulty falling asleep and intermittent wakefulness during sleep. Treatment of insomnia involves behavioral changes, such as minimizing habits that interfere with sleep (for example, drinking coffee or engaging in stressful activities in the evening), and pharmacotherapy with sedating antidepressants (for example, trazodone), sedating antihistamines, anticholinergics, benzodiazepines, or nonbenzodiazepine hypnotics. The benzodiazepines and the newer sedative hypnotics zolpidem, zaleplon, zopiclone, and eszopiclone work through gamma-aminobutyric acid receptors. Ramelteon, a hypnotic approved by the United States Food and Drug Administration (FDA) in July 2005, is a selective melatonin receptor (MT1 and MT2) agonist. New nonbenzodiazepine drugs have been sought for multiple reasons, including reduction of the risk of tolerance, dependence, and abuse associated with benzodiazepines. The purpose of this review is to evaluate the comparative evidence on benefits and harms of these medications in people with insomnia to help policymakers and clinicians make informed choices about the use of newer drugs for insomnia.

Drug Class Reviews - Oregon Health & Science University.

Version: October 2008
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Off-Label Use of Atypical Antipsychotics: An Update [Internet]

Antipsychotic medications are approved by the U.S. Food and Drug Administration (FDA) for treatment of schizophrenia, bipolar disorder, and for some drugs, depression. We performed a systematic review on the efficacy and safety of atypical antipsychotic drugs for use in conditions lacking FDA approval.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: September 2011
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Drug Class Review: Atypical Antipsychotic Drugs: Final Update 3 Report [Internet]

Atypical antipsychotic agents are used to treat the symptoms of schizophrenia and bipolar disorder. The purpose of this review is to help policy makers and clinicians make informed choices about their use. Given the prominent role of drug therapy in psychiatric disease, our goal is to summarize comparative data on efficacy, effectiveness, tolerability, and safety. Ten atypical antipsychotics are currently available in the United States and Canada. Clozapine, the prototypic atypical antipsychotic, was introduced in 1989. Since then, 9 other atypical antipsychotics have been brought to market: risperidone (1993), risperidone long-acting injection (2003), olanzapine (1996), quetiapine (1997), ziprasidone (2001), aripiprazole (2002), extended-release paliperidone (2006), asenapine (2009), iloperidone (2009), and paliperidone long-acting injection (2009).

Drug Class Reviews - Oregon Health & Science University.

Version: July 2010
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Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults [Internet]

This review from the RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center (EPC) provides a comprehensive summary of the available data addressing the comparative effectiveness of four nonpharmacologic treatments as therapies for patients with treatment-resistant depression (TRD): electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), and cognitive behavioral therapy or interpersonal psychotherapy (CBT or IPT).

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: September 2011
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Pain Management Interventions for Hip Fracture [Internet]

To review and synthesize the evidence on pain management interventions in nonpathological hip fracture patients following low-energy trauma. Outcomes include pain management (short and long term), mortality, functional status, pain medication use, mental status, health-related quality of life, quality of sleep, ability to participate in rehabilitation, return to pre-fracture living arrangements, health services utilization, and adverse effects.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: May 2011

Traumatic Brain Injury and Depression [Internet]

The Vanderbilt Evidence-based Practice Center systematically reviewed evidence addressing key questions on depression after traumatic brain injury, including prevalence, optimizing timing and methods for diagnostic screening, and approaching treatment.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: April 2011
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Drug Misuse: Opioid Detoxification

The guideline on Drug misuse: opioid detoxification, commissioned by NICE and developed by the National Collaborating Centre for Mental Health, sets out clear, evidence-based recommendations for healthcare staff on how to work with people who misuse opioids to significantly improve their treatment and care, and to deliver detoxification safely and effectively. Of the estimated 4 million people in the UK who use illicit drugs each year, approximately 50,000 misuse opioids (such as heroin, opium, morphine, codeine and methadone). Opioid misuse presents a considerable health risk and can lead to significant social problems. This NICE guideline is an important tool in helping people to overcome their drug problem.

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK).

Version: 2008
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Medical Encyclopedia

  • Delirium
    Delirium is sudden severe confusion due to rapid changes in brain function that occur with physical or mental illness.
  • Delirium tremens
    Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or nervous system changes.
  • Alcohol withdrawal
    Alcohol withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol.
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Systematic Reviews in PubMed

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